By Q. Mazin. Lawrence Technological University.
These data are different from some of those reported earlier buy discount remeron 15mg on-line, in that they do not show undertreatment of an eth- nic group. Both groups of women had equal (albeit high) levels of pain at the time of assessment; what differed was the pain level judged by the de- livery staff from the exhibited behavior. It is uncertain whether this differ- ence was due to the behavior of the two groups, a bias on the part of the medical personnel, or their inability to recognize signs of pain in patients of a different culture. Pain Expression Diagnosis and treatment of pain are largely dependent on what the patient is willing to tell the health care provider or, for that matter, thinks is suffi- ciently important to report. The ethnocultural background of the practition- er is also likely to interact with that of the patient; a good physician or psy- chologist should examine his or her own attitudes and expectations about pain behavior. Davitz, Sameshima, and Davitz (1976), for example, asked over 500 nurses in the United States, Japan, Taiwan, Thailand, Korea, and Puerto Rico to read descriptions of patients and to judge their pain and psy- chological distress. The descriptions were brief and, in their own language, covered five disease categories, both sexes, three age levels, and two de- grees of severity. The study found that Japanese and Korean nurses be- lieved that their patients suffered a high degree of pain, while American and Puerto Rican nurses rated their patients’ pain fairly low. ETHNOCULTURAL VARIATIONS IN PAIN 163 counter to the stereotype of Asian stoicism. Consequently, Asian patients treated in North American hospitals might receive less treat- ment than their pain level would warrant. Interestingly, other stereotypes, which could be quite dangerous to the patient, were shared by the nurses in all six cultures. For one, males were seen as in less pain than females for similar degrees of emotional distress. For another, the nurses believed that children suffer far less psychological distress than adults for comparable levels of pain.
Balady GJ purchase remeron 15mg overnight delivery, Ades PA, Comoss P, et al: Core components of car- After exercise, patients should monitor serum glucose diac rehabilitation/secondary prevention programs: A state- levels and be alert for signs and symptoms of either ment for healthcare professionals from the American Heart hypoglycemia or hyperglycemia. Association and the American Association of Cardiovascular and Pulmonary Rehabilitation Writing Group. Evidence-based nutrition principles and recommendations for the CORONARY ARTERY DISEASE treatment and prevention of diabetes and related complica- tions. Philadelphia, reduced in patients suffering a myocardial infarction Lippincott, Williams & Wilkins, 2000, pp 165–199. Promoting and prescribing exercise for the guidelines regarding staffing, supervision, and progres- elderly. Physical activity PREGNANCY and health: A report of the surgeon general. Atlanta, GA, US Department of Health and Human Services, Centers for Physical activity is safe for pregnant patients and should Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996. Healthy People mulate 30–60 min of moderate physical activity at least 2010: Understanding and Improving Health. Washington, DC, three times per week (American College of Obstetricians US Department of Health and Human Services, Government and Gynecologists, 1994). Behavioral counseling in pri- As pregnancy progresses, a pregnant woman’s center mary care to promote physical activity: Recommendations and of gravity changes, and she should be counseled to rationale. The Surgeon General’s Call to Action Centripetal obesity in which the waist-to-hip ratio is to Prevent and Decrease Overweight and Obesity. Rockville, high indicates a subset of individuals at much higher MD, US Department of Health and Human Services, Public risk of cardiovascular diseases (Perry et al, 1998).
Long head of the biceps tendon buy 30 mg remeron with amex, deltoid, and teres major Static Stabilizers Include the articular anatomy, capsule, ligaments, as well as the glenoid labrum MUSCULOSKELETAL MEDICINE 137 MEDIAL ROTATORS Pectoralis major Anterior deltoid Subscapularis Latissimus dorsi Teres major LATERAL ROTATORS Teres minor Posterior deltoid Infraspinatus FIGURE 4–10. This diagram depicts the relation of the rotators to the upper end of the humerus. Right glenoid cavity of the scapula as viewed from the anteriolateral aspect. Note four short rotator cuff muscles (teres minor, infraspinatus, supraspinatus, and subscapularis). Note the contribution of the coraco-acromial ligaments to the inferior acromio-clavicular joint capsule. Acromioclavicular (AC) ligament Connects the distal end of the clavicle to the acromion, providing horizontal stability 2. Coraco-clavicular (CC) ligament This ligament is made up of 2 bands: Conoid and trapezoid Connects the coracoid process to the clavicle, providing vertical stability 3. Coraco-acromial ligament Connects the coracoid process to the acromion Mechanism of Injury A direct impact to the shoulder Falling on an outstretched arm MUSCULOSKELETAL MEDICINE 139 Classification of AC Joint Separations (See Figure 4–13) TABLE 4–1 Ligament Acromioclavicular Coracoclavicular Clavicular Displacement Type I Partial sprain Intact None Type II Complete tear Partial sprain None Type III Complete tear Complete tear Superior Type IV Complete tear Complete tear Posterior and superior into the trapezius, giving a buttonhole appearance Type V Complete tear Complete tear Superior and posterior More severe than type III with coracoclavicular space increased over 100%. Type VI Complete tear Complete tear Inferior Clinical Patients generally complain of tenderness over the AC joint with palpation and range of motion AC joint displacement with gross deformity occurs in the later stages and is usually seen in a type III or greater Provocative tests Cross-chest adduction Passive adduction of the arm across the midline causing joint tenderness Imaging Weighted AP radiographs of the shoulders (10 lbs) – Type III injuries may show a 25% to 100% widening of the clavicular-coracoid area – Type V injuries may show a widening > 100% Treatment Depends on the degree of separation Acute Types I and II – Rest, ice, nonsteroidal anti-inflammatory (NSAIDs) – Sling for comfort – Avoid heavy lifting and contact sports – Shoulder-girdle complex strengthening – Return to play: When the patient is asymptomatic with full ROM Type I: 2 weeks Type II: 6 weeks Types III or greater: Controversial – Conservative or surgical, depending on the patient’s need (occupation or sport) for particular shoulder stability – Surgical: For those indicated (heavy laborers, athletes) – Generally, no functional advantage is seen between the two treatment regimens Types IV to VI – Surgery is recommended: Open reduction internal fixation (ORIF) or distal clavicular resection with reconstruction of the CC ligament 140 MUSCULOSKELETAL MEDICINE Chronic AC joint pain Corticosteroid injection May require a clavicular resection and CC reconstruction Complications Associated fractures and dislocations Distal clavicle osteolysis – Degeneration of the distal clavicle with associated osteopenia and cystic changes FIGURE 4–13. Classification of AC Joint Separations (Anterior Views) (see Table 4–1 for description). MUSCULOSKELETAL MEDICINE 141 AC joint arthritis – May get relief from a lidocaine injection and conservative rehabilitative care should be sufficient GLENOHUMERAL JOINT INJURIES (GHJ) General Glenohumeral joint type: Ball and socket Scapulothoracic motion or glenohumeral rhythm – Balance exists between the glenohumeral and scapulothoracic joint during arm abduc- tion – There is a 2:1 glenohumeral: scapulothoracic motion accounting for the ability to abduct the arm (60˚ of scapulothoracic motion to 120˚ of glenohumeral motion) – The scapulothoracic motion allows the glenoid to rotate and permit glenohumeral abduction without acromial impingement Classification of GHJ Instability Definitions Instability is a translation of the humeral head on the glenoid fossa without complete sep- aration. It may result in subluxation or dislocation Subluxation is a separation of the humeral head from the glenoid fossa with immediate reduction Dislocation is complete separation of the humeral head from the glenoid fossa without immediate reduction Direction of Instability Anterior glenohumeral instability – Most common direction of instability is anterior inferior – More common in the younger population and has a high recurrence rate – Mechanism: Arm abduction and external rotation – Complication may include axillary nerve injury Posterior glenohumeral instability – Less common than anterior instability – May occur as a result of a seizure – The patient may present with the arm in the adducted internal rotated position – Mechanism: Landing on a forward flexed adducted arm Multidirectional Instability – Rare with instability in multiple planes – The patient may display generalized laxity in other joints Patterns of Instability Traumatic: T. T- Traumatic shoulder instability U- Unidirectional B- Bankart lesion S- Surgical management (Rockwood, Green, et al.